CV_2 Flashcards
1
Q
Oxygen delivery to heart equation
A
Oxygen delivery = coronary blood flow* oxygen content
2
Q
What are 5 ways smoking confers a 50% increase in cardiovascular disease risk?
A
- Thrombogenic
- Compounds prmote atherosclerosis
- Endothelial dysfunction/vasospasm
- CO decreases oxygen delivery
- Decreased HDL
3
Q
What is the dyslipidemic triad?
A
High LDL
Low HDL
High triglycerides
They are independent risk factors
4
Q
When heart rate increases, what part of the heart contraction cycle shortens?
A
Diastole. Thus, tachycardia can compromise coronary flow
5
Q
How do you increase myocardial O2 supply?
A
Increase blood flow, since the heart can’t increase oxygen extraction
6
Q
What is the Law of Laplace?
A
Myocardial wall tension is proportional to cavity pressure, cavity dimension, and 1/ wall thickness
T oc P*L/WT
7
Q
Acute myocardial infarction is also called ___________
A
Unstable angina
8
Q
What are the 2 most common vessels used for coronary bypass surgery?
A
Mammary artery
Saphenous vein
9
Q
What is the primary component of large arteries, small arteries, and arterioles?
A
Elastin
Collagen
Smooth muscle
10
Q
Can LDL enter the endothelium?
A
Not under normal conditions. It can only enter disrupted/abnormal endothelium
11
Q
What is the composition of venous and arterial thrombi? Where do they occur? What drug classes are used to treat?
A
Venous: fibrin and RBC-rich. Occur in areas of stasis. Treat with anticoagulants.
Arterial: platelet-rich. Occur in areas of high flow. Treat with antiplatelets.
12
Q
What measureable thing is elevated in myocyte necrosis?
A
Troponin enzymes (I and T)
Begin 3-12 hours after injury and peak 18-24 hours after necrosis begins
13
Q
What does LDL bind to in the intima, resulting in entrapment?
A
ECM proteoglycans
14
Q
What is the pathophysiological difference between STEMI, NSTEMI, and unstable angina??
A
STEMI - complete coronary vessel occlusion
NSTEMI - partial coronary vessel occlusion with myocardial necrosis
Unstable angina - partial coronary vessel occlusion without myocardial necrosis
15
Q
Draw the serum markers of myocardial necrosis chart
A
Mrr
16
Q
What is the difference between stable and unstable angina?
A
Unstable is when angina symptoms change and are worse
Unstable is on the spectrum of acute coronary syndrome and stable angina is not
17
Q
What are the 2 ways to reduce artery occlusion in STEMI (complete coronary artery occlusion)?
A
Cardiac catheterization
Fibrinolytics - if can’t be opened within 90 minutes or cath lab is not available
18
Q
What is coronary autoregularion?
A
When coronary blood flow responds to coronary artery pressure to keep it at a certain level. So, when pressure increases, blood vessels relax and stuff.
Occurs at level of small arterioles
19
Q
How well does angiography estimate the size and severity of coronary artery disease?
A
It usually underestimates it because it can only observe lumenal diameter.
20
Q
What are 5 upregulators of nitric oxide?
A
Shear stress Acetylcholine Serotonin Thrombin Bradykinin
21
Q
What are the differences in composition between a stable and vulnerable plaque?
A
Stable - fibrous, more calcified, less lipid, less inflammation, less apoptosis
Vulnerable - less fibrous, less calcified, more lipid, more inflammation, more apoptosis
22
Q
What is the distribution of atherosclerotic plaques?
A
Dorsal abdominal aorta and proximal coronary arteries -> popliteal arteries -> descending thoracic aorta -> internal carotid arteries -> renal arteries
23
Q
2 anti-platelet drugs
A
Aspirin Plavix (clopidogrel)
24
Q
Aspirin Plavix (clopidogrel)
A
Arginine
Nitric oxide synthase
25
What is the route of administration for heparin?
IV – immediate
SubQ – delayed
It is not absorbed from the gut!
26
What is the antidrug to heparin?
Protamine
It is a strongly + charged drug that complexes with the strongly – charged heparin
27
What are the advantages to low molecular weight heparin?
Longer half-life
Better bioavailability
More predictable dose response, so can be given outpatient
28
Which drug acts in the plasma to directly inhibit the activity of factor Xa?
Rivaroxaban
29
Which drug acts in the plasma to directly inhibit thrombin?
Dabigatran
30
What does streptokinase do?
Activates plasminogen
It's from strep!
31
Nitric oxide synthase is expressed on the ____________ side of the endothelium
Luminal
32
Nitric oxide synthesis is ____________-mediated vasodilation
cGMP
33
What part of the heart wall is most often not perfused?
Subendocardium (so the inside of the wall)
Because blood vessels are on the outside
34
What are the 3 classifications of acute coronary syndrome? Draw table
Unstable angina - ST depression (may look normal when no pain); partial occlusion; no serum biomarkers
NSTEMI - ST depression; partial occlusion; no serum biomarkers
STEMI - ST elevation; total occlusion; serum biomarkers
35
Which vascular beds increase blood flow in exercise?
ONLY the muscle and coronary ones
36
What is acute coronary syndrome?
Atherosclerotic plaque rupture or thrombosis
37
Within what time frame do you need to be sent to the cath lab?
90 minutes
38
What is drug treatment protocol for unstable angina/NSTEMI?
2 antiplatelet agents: aspirin + P2Y12 inhibitor. If going to cath lab/high risk, consider a GP IIa/IIIb inhibitor
1 anticoagulant. If going to cath lab give bivalirudin
39
Where are the 3 natriuretic peptides found?
Atrial - atrium
B - ventricles
C - endothelium
40
What causes BNP levels to rise?
Increased stretch due to increased volume in ventricles
41
What are 3 cases in which BNP levels can be higher than expected?
What is a normal value?
Women
Elderly
Renal insufficiency
42
What are berry aneurysms?
Congenital defects in the media of arteries at the bifurcation of cerebral vessels
43
What is ischemic heart disease? What accounts for most of it?
Myocardial oxygen requirement > cardiac blood supply
Obstructive coronary atherosclerosis accounts for >90%
44
What are 5 causes of injury due to reperfusion?
```
Mitochondrial dysfunction
Calcium influx -> hypercontracture
Free radical damage
Leukocyte aggregation
Platelet and complement activation
```
45
At what time do irreversible ultrastructural changes occur in MI?
1-2 hours
46
What are wavy fibers and at what time do they occur?
Non contractile ischemic fibers stretched with each systole
| 4-12 hours after MI
47
At what time point does coagulation necrosis and neutrophil infiltration occur in MI?
18-24 hours
| 24-72 hours for maximum
48
Describe gross pathology of infarcts and their time course
4-7 days - macrophages with disintegration of myocytes. Pallor with hyperemic border
10 days - granulation tissue. Yellow, soft with dark border
4-8 weeks - fibrosis. Firm, gray
49
Why is myocardial hypertrophy vulnerable to ischemia?
The capillary bed does not expand in step
50
What is the difference in structure in pathological and physiologic cardiac hypertrophy?
Concentric - muscles added in parallel
Muscle added in series
51
What are 3 causes of secondary hypertension?
Renal
Endocrine
Vascular
52
The most frequent cause of aneurysm is _________________
Atherosclerosis
53
Dissection is usually due to a defect in which layer of an artery?
Intima
54
___________ takes triglycerides out of the chylomicron into cells
Lipoprotein lipase
55
What does lipoprotein lipase do?
Takes triglycerides out of the chylomicron into cells
56
The chylomycron with much of the TG removed is ___________
LDL
57
What does PCSK9 do?
Prevents LDL receptors from going to the surface so it's harder to clear cholesterol
58
LDL blood test equation
LDL = total cholesterol - HDL - (TG/5)
59
Categorize the vasculitises
Large vessel: Takayasu's arteritis, termporal arteritis
Medium vessel: Vuerger's disease, cutaneous vasculitis, Kawasaki disease, polyarteritis nodosa
Small vessel: Chur-Strauss, microscopic polyangiitis, ganulomatous with polyangiitis, cryoglobulinemia
60
What is the main difference between giant cell arteritis and Takayasu's arteritis?
Takayasu's generally affects young people from Asia and doesn't affect the temporal artery
Giant cell arteritis mostly affects people of northern european background
61
What is an erosion type plaque?
Eroded/missing endothelilal layer at plaque-thrombus interface
Sparse inflammation, usually no calcification
62
What is the difference in usual cause between a transmural and subendocardial infarction?
Transmural - thrombus occluding a coronary artery
| Subendocardial - hypoperfusion of heart
63
Are most people right or left heart dominant? What does this mean?
80% of people are right-heart dominant
| Their posterior coronary artery comes off the RCA
64
When is the heart most vulnerable to rupture?
3-7 days after a transmural infarct. This is when necrosis has set in but fibrosis hasn't yet developed
65
Where is the most common site of atherosclerotic aneurysms?
Lower abdominal aorta below renal arteries
66
What characterizes giant cell arteritis?
Granulomatous vasculitis, particularly of the temporal artery
67
How do you treat giant cell arteritis?
Corticosteroids
68
What characterizes polyarteritis nodosa?
Acute segmental necrotizing vasculitis involving small and medium sized arteries of the kidneys, GI tract, heart
69
What antibody is often present in polyarteritis nodosa?
P-ANCA (perinucleur antineutrophil cytoplasmic autoantibodies)
70
How do you treat polyarteritis nodosa?
Anti-inflammatory/immunosuppressive
71
What characterizes wegener's granulomatosis?
| What antibody is often present?
Idiopathic necrotizing granulomatous vasculitis of small to medium size arteries and veins (it's a small vessel vasculitis) involving the upper and lower respiratory tracts and kidneys
C-ANCA (cytoplasmic anti neutrophilic cytoplasmic antibodies)
72
What is churg strauss syndrome?
Systemic vasculitis of small arteries and veins in young people with asthma and eosinophilia, mostly ivolving the lungs
73
What is granuloma pyogenicum?
A reactive process where polypoid granulation tissue-like nodule on skin or mucosal surfaces
In trauma or pregnancy (wher eit often regresses)
74
What is a malignant vascular tumor called?
Angiosarcoma
75
What test do we use to monitor heparin therapy?
PTT (woodpecker)
76
What test do we use to monitor warfarin therapy?
PT (paratrooper)
| INR (intercom radio)
77
What is ecarin clotting time?
Derived from the venom of the saw-scaled viper
| Monitor anticoagulation therpy with direct thrombin inhibitors (hirudin and dabigatran)
78
How does heparin work?
It binds to and accelerates the activity of antithrombin III to inhibit activated clotting factor proteases
79
Which anticoagulant is safe to use in pregnancy?
Heparin
| Warfarin is not!
80
What are 4 adverse reactions to heparin?
Hemorrhage
Hypersensitivity
Thrombocytopenia (greater with higher molecular weight; skeet shooting)
Osteoporosis (bone tree)
81
What organ does warfarin act on?
Liver
82
Which factors does warfarin act on?
```
C, S (sargeants)
II - beaver
7 - devil (deadly sins)
9 - cat (9 lives)
10 - fox
```
83
What enzyme metabolizes warfarin?
CYP2C9 - potential effects!
84
What do you give in event of a warfarin overdose?
Vitamin K
| Prothrombin complex concentrate or fresh frozen plasma
85
How does aspirin work?
Inhibition of COX1 and COX2, inhibiting platelet aggregation
86
How does clopidogrel work?
ADP receptor antagonist (Aggregate Da Players), inhibiting platelet aggregation
87
How does dipyridamole work?
Blocks phosphodiesterase breakdown of cAMP, elevating cAMP and potentiating prostacyclin's anti-aggretory action
Pyramid tent advertising signing up for camp and sign 'don't PHoster Disinterest'
88
What do abciximab, aptifabitide, and tirofaban do?
Block IIb/IIIa receptors on platelts, reducing aggregation
89
What are the 3 IIb/IIIa blockers?
Abciximab (ABC news)
Eptifabatide (tied score)
Tirofiban (tied score)
90
How do you take aspirin in an acute myocardial infarction?
Chewed and swallowed
91
What are the 3 major determinants of myocardial oxygen consumption?
Contractile state
Heart rate
Myocardial wall tension
92
What is the goal of chronic pharmacotherapy for angina?
| What 3 drug classes are used?
The goal is to reduce oxygen demand with
Nitrates
Calcium channel blockers
Beta-blockers
93
What is the goal of treatment of variant/Prinzmetal angina?
| What 2 drug classes are used to treat?
Reversing/preventing vasospasm with:
Nitrates
Calcium channel blockers
94
What does NO do?
Activates guanylate cyclase
Increases converstion og GTP to cGMP
cGMP leads to myosin light chain dephosphorylation, preventing its interaction with actin
This causes relaxation
95
What are 4 side effects of therapeutic vasodilation?
Headache
Orthostatis hypotension
Reflex tachycardia
Facial flushing
96
What are the 3 calcium channel blockers we care about?
Verapamil (Very vanilla)
Diltiazem (Dark chocolate)
Nifedipine (Fudge)
97
Fick equation
CO = VO2/[a-vO2)
98
The largest pressure drop in the vascular system occurs across the ______
Arterioles
99
How do you claculate mean arterial pressure?
Diastolic BP + (S-D)/3
100
How are flow and vessel radius related?
Q oc r^4
101
What is the primary means of venous blood return from the lower extremities?
Calf muscle pump
102
Which layer does atherosclerosis occur in?
Intima
103
7 steps of atherosclerosis
```
Fatty streak
Endothelial dysfunction
Lipoprotein entry and modification
Leukocyte recruitemnt
Foam cells
SMC migration
Plaque progression/disruption
```
104
What makes the majority of an atherosclerotic cap's contents?
SMCs
105
How do statins work?
They are HMG-CoA inhibitors
This is the rate-limiting enzyme in cholesterol biosynthesis
Less cholesterol in cells -> LDL receptor upregulation -> cholesterol is removed from blood
106
What does PSK9 do in cholesterol cycle?
It binds to the LDL receptor and tells it to break down
107
How does the lumen size change in atherosclerosis?
It compensates for a while, staying the same size
| Eventually as the plaque grows more, it shrinks
108
What are 5 ways statins 'stabilize' plaques?
Reduce lipid content
Decrease inflammatory cells
Decrease MMP and tissue factor activation
Decrease thrombogenesis
Increased fibrosity - decreased plaque rupture
109
What are the ages for premature coronary heart disease?
Males
110
What is severe hypertriglyceridemia associated with?
Acute pancreatitis
111
Has lowering triglycerides or raising HDL been shown to reduce death/increase health?
Nope! It remains unclear
112
How does fractional flow reserve work?
Coronary catheterization to compare pressure differences in arteries. If there is a drop, there is likely a stenosis
113
How long after quitting smoking does your risk of coronary events return to normal?
10 years
114
Information regarding a patient's INR is utilized in the management of patients who are taking __________________
Warfarin
115
Indirect thrombin-Xa inhibitors have _______ in their names
| Direct thrombin inhibitors have ________
parin
| rudin
116
In which situation would you use heparin vs. LMWH?
Renal impairment, since it is renally eliminated
| Heparin effect is more rapidly and completely reversed by protamine
117
What is the difference between what dabigatran vs. rivaroxaban inhibits?
Thrombin
| Xa
118
What is the target of warfarin?
Vitamin K epoxide reductase (V-KOR supply boat)
119
How are dabigatran and rivaroxabaneliminated?
Prodrug converted by esterases; renaly excreted
| Hepatic metabolism by a CYP; renally excreted
120
What are 3 side effects of warfarin?
Necrosis of fatty soft tissues (because of increased coagulability in first doses)
GI
Osteoporosis
121
What is class III data?
Recommendations indicate therapy should not be performed
122
What class of antiplatelet drug does clopidogrel belong to?
P2Y12 antagonist
123
How do P2Y12 receptor blockers work?
They block binding of ADP to a platelet receptor P2Y12
Inhibits activation of the GP IIb/IIIa complex
Inhibits platelet aggregation
124
What should your blood pressure be below?
140/90
125
How do diabetes and prior MI compare as mortality risks?
They confer equal mortality reisks
126
What on activated endothelium (1) attaches to what on monocytes (2), allowing them to adhere?
VCAM-1 ataches to CD11c (integrin) and VLA-4 (tight adhesion)
127
Which T cells are active in atherogenesis?
Th1 - promotes IFN-gammma
| TH17 - plaque instability and neoangiogenesis
128
What 3 things does CRP respond to?
| What is its downstream effect?
Modified membranes
Apoptotic cells
Lipoproteins
It activates the classical complement pathway
129
What is the suffix for fibrinolytic agents?
-teplase`
130
What are the 2 main symproms of peripheral artery disease?
Claudication
| Ischemic rest pain/ischemic ulcers/gangrene
131
What ratio of the ankle-brachial index is cause for concern?
How do you calculate it?
.9>x>1.3
Arm BP/ankle BP
132
What defines an aneurysm?
Increase in diameter by >50%
133
4 mechanisms of aneurysm formation
Weakened aortic wall
Inflammation
Proteolytic enzymes
Biomechanical stresses
134
2 mechanisms of aortic dissection
Intimal tear
| Rupture of vasa vasorum
135
What is Virchow's triad?
Abnormal flow
Injury
Coagulation changes
136
What are 3 factors that influence venous return?
Venoconstriction
Muscle pump
Respiratory pump - negative pressure draws blood back to heart, especially during strenuous exercize
137
What is rate pressure product?
| 3 components of rate pressure product
An index of myocardial oxygen consumption
HR^2
P
V
138
What are the 5 parts of the heart tube?
```
Truncus
Bulbus cordis
Primitive ventricle
Primitive atria
Sinus venosus
```
139
Which direction does the primitive heart loop?
To the right of the embryo so that the ventricles are in front, atria behind
140
Which part of the heart is the pulmonary artery/aorta attached to in the embryo?
The right ventricle
141
What is the embryologic conus?
The outflow tract of the ventricle
142
What does the truncus become?
Aortic/pulmonary valves
Ascending aorta
Pulmonary trunk
143
In the embryo, blood enters th eheart tube through the sinus venosus via 3 sets of veins:
Umbilical - from placenta
Vitelline - from yolk salk
Cardinal - drains embryo
144
What are the 2 conal crests that fuse with the ventricular septum?
Dextrodorsal
| Sinistroventral
145
How do myocardial wall thickness and oxygen consumption compare?
They are inversely proportional
Wall stress is less,so consumption is less
146
What are the 4 parts of the tetralogy of Fallot?
1. RV outflow tract obstruction
2. RV hypertrophy
3. Dextraposition of the aorta so that the aorta overrides the ventricular septal defect
4. Ventricular septal defect
This is all due to the anterior and superior deviation of the infundibular part of the ventricular septum
147
What is a blue vs. pink tet?
Tetralogy of Fallot
Blue from R to L shunt if RV outflow resistance > systemic vascular resistance -> cyanosis
Pink from L to R shunt if RV outflow resistance no cyanosis
148
How do you treat a tet spell (4)?
Knee to chest - increased systemic vascular resistance
Phenylephrine - increases SVR
Morphine - sedative
Volume expansion with IV fluids
149
At what age do you repair tetralogy of Fallot?
2-4 months
150
What disease is associated with coarctation of the aorta?
Turner Syndrome (15%)
151
What's an important thing on physical exam that can indicate coarctation of the aorta?
Absent/weak femoral pulses
152
What is the 3 sign in older children and adults on cardiac X ray?
Aortick knob - coarctation - post-stenotic dilation looks like a 3?
Also might see rib notching - dilated intercostal arteries
153
What are 3 risk factors for congenital cardiac defects?
Male
Maternal diabetes
Cardiac defect in a first degree relative
154
What are 2 risk factors for patent ductus arteriosus?
Above 9000 feet elevation
| Maternal rubella
155
The ductus is derived from what?
DIstal portion of left 6th aortic arch
156
What drug maintains ductal patency?
Prostaglandins
157
What 2 drugs can close a PDA?
Indomethacin - protects against intraventricular hemorrhage, but decreases blood flow to kidneys/brain
Ibuprofen - prefered with renal disease
158
How do the time points of atrial an ventricular septation compare?
THey occur at the same time
159
What are the 2 causes of a secundum atrial septal defect?
Too large a central hole in septum primum (the osteum secundum)
Inadequate development of septum secundum
160
What is a dependent shunt?
One hwere blood flow is dependent on pressure and resistance
161
What causes the murmur in an atrial septal defect?
It is NOT related to blood going across the defect?
Systolic ejection murmur - excessive blood flow across pulmonary valve
Diastolic rumble - excessive blood flow across the tricuspid valve
162
What happens to S2 in an atrial deptal defect?
A2-P2 split is more prominent b/c of higher RV pressures than normal
(split usually occurs during inspriation)
163
Which way does the ventricular septum grow?
From apex to base (the base is where the valves are)
164
What are the 4 endocardial cushions?
Inferior
Superior
Left
Right
165
Which part of the ventricular septum is most often defective?
The membranous portion (the part closest to the valves)
Muscular portion is a distant second
166
What defines a large ventricular defect?
| What is an important feature?
Those that are the same diameter as the aortic orifice
| These are often unrestrictive
167
What is eisenmenger's syndrome? (7)
Large L->R shunt
Increased pulmonary blud flow
Muscularizaiton of pulmonary arterioles (irreversible at this point)
Increased RV pressure
Shunt reversal (patient will die if hole closed at this point)
Cyanosis and clubbing
Heart/lung transplant or death
168
What ae the 2 cardinal symptoms of depression? Do patients always have both?
Loww of interest or pleasure from important activiteis - anhedonia
Depressed mood, most of the day, nearly every day
Patients may have one or both
169
How long does a depressive episode usually last in major depressive disorder?
6-24 months
170
What is dysthymia?
Persistent depressive disorder
| Dysthymic Eeyore
171
What drug do you use for a pharmacologic stress test?
Dobutamine
172
Statins inhibit ______
HMG-CoA reductase
This is the rate-limiting step in the cholesterol production pathway
173
What are 5 physiologic derangements associated with depression?
```
Autonomic dysfunction (reduced HR variability)
Elevated cortisol
Platelet activation
Endothelial dysfunction
Inflammation
```
174
Depressed patients have elevated brain ______ turnover.
Serotonin
175
Which part of the brain is overstimulated in depression?
Amygdala
176
Do beta blockers cause depression?
No!
177
3 anti-ischemic drug classes
Beta blockers
Nitrates
Calcium channel blockers
178
4 contraindications to fibrinolytics
Active peptic ulcer disease
Underlying bleeding disorders
Recent stroke
Recovering from recent surgery
179
What drug is used for claudication?
Cilostazol
180
2 drug classes that reduce mortality of atherosclerosis
Statins
| ACEI
181
4 major statin benefit groups
1. ASCVD
2. High LDL
3. Diabetes
4. estimated 10-years ASCVD risk >=7.5%
182
Can you take statins in pregnancy?
Nope!
183
3 side effects of nitrates
Extensions of therapeutic vasodilation:
Headaches
Syncope/hypotension
Reflex tachycardia
184
Which calcium channel bockers have effects at cardiac nodal tissue?
Verapamil
| Diltiazem
185
_________ surrounds heart tubes on day 19
Splanchnic mesoerm
186
__________________________ lines the heart tubes
Endothelial cells
187
Septation begins at the ___________ stage o heart looping
Post-loop
188
_________________ becomes tihe intraventricular septum
Atrioventricular sulcus
189
What medical therapies are available for atrial septal defect?
Diuretics in infants to relieve breathlessness
190
Why do people squat with tetralogy of Fallot?
Increases systemic vascular resistance, forcing more blood to go out to the lungs
191
What 4 drugs do you give for MI?
```
Morphine
Oxygen
Nitroglycerin
Aspirin
(Mona)
```
192
What drug class is amlodipine?
Calcium channel blocker
193
What do nitrates do?
Decrease ventricular preload by dilating veins and dilating coronary arteries a little bit
